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PHARMACEUTICAL CARE
BIDANG GERIATRI
STEMI INFERIOR 3 VD, DM2, PAF, AKI
.
Senin, 23 Okt
Identitas Pasien
■ Nama : Ny R
■ No CM : 01 02 25 **
■ Alamat : Yogya
■ Tanggal lahir : 1 Feb 19467
(70 tahun)
■ BB/TB : 50 kg/ 145 cm
■ Diagnosa :
1. Stemi Inferior
2. DM2
3. AKI
4. PAF
■ Bangsal : Anggrek 1 km 1
■ Status pasien : JKN non PBI
■ MRS : 13/12/2017
■ KRS : 19/12/2017
Data Subjektif
Keluhan Utama MRS: Nyeri Dada
RPS: ± 1 hari SMRS mengeluh nyeri pada dada sebelah kiria setelah menyapu
pada sore hari, makin memberat pada malam hari. Pasien sempat
mengatakan minta dikerok namun tidak sembuh nyeri makin hebat dan
sesak. Pasien sempat dibawa ke rs panti nugroho merasakan sesak nafas
dan gelisah  dikatakan EPA dan sempat dilakukan intubasi
RPD: -
ROD: Pasien sempat diberikan obat saat di rs panti nugroho yaitu aspilet 320 mg,
clopidogrel 300 mg, ISDN 5 mg SL, Furosemid 2 ampul, morfin 2 mg,
omeprazole 1 A, Novorapid 4 UI
Aspek Geriatri: ADL premorbid  dibantu sebagian
Kognitif  baik
Mental  baik, tidak ada stress
Support system  tinggal serumah dengan anak
Alergi Obat: -
Data Objektif
Parameter
Tanggal
13/12
ICCU
14/12 15/12 16/12 17/12 18/12 19/12
TD (mmHg) 150/80 140/80 138/80 146/78 124/63 114/60 105/75
Nadi (x/mnt) 82 80 80 72 68 68 70
RR (x/mnt) 20 20 22 22 20 18 18
Suhu (oC) 36,7 36,8 36,8 36,1 36,2 36
SpO2 (%) 95,5 97,5 97,5 93 99
Tanda-tanda Vital
Parameter
Tanggal
13/12
IGD
14/12 15/12 16/12 17/12 18/12 19/12
KU Sdg CM Sdg CM Sdg CM Sdg CM Sdg CM Sdg CM Sdg CM
Lemas + + + + + + +
Sesak
Nafas terasa
berat
+ + - - - -
Perkembangan Klinis
Data
Laboratorium
Parameter Nilai Rujukan
13/12 14/12 15/12 16/12 17/12 18/12
AL
4,5 – 11,5
Rb/MMk
14,3
Hb 13 - 18 g% 9,6
Hmt 40 - 54 % 29,0
BUN 6-20 mg/dL 17,8 38
Creatinin 0,7 - 1,2 mg/dL 1,46 2,03
CCT mL/min 28
GDS 80-140 mg/dL 236
GDP 80 - 110 mg/dL 187 178 189
HbA1c < % 7 8,5%
LDL direct mg/dL 130
SGOT 5-35 u/L 43
SGPT 5-35 u/L 22
PTT 10 - 15 detik 19,2
aPTT 21 - 45 detik 36,1 69,4 72,7 55,7 92
INR 0,80-1,20 detik 1,18 1,49
Na
135-144
mmol/L
142
K 3,5-5,1 mEq 3,37 4,86
Cl 97-106 mmol/L 111
Perhitungan
ClCr
Umur: 70 tahun
BB/TB = 50 kg/145 cm
𝐵𝑀𝐼 =
50 𝑘𝑔
(1,45)2 = 23,78 kg/m2
■ Tgl 13/12 cr = 1,46 mg/dL
ClCr =
140−𝑢𝑚𝑢𝑟 𝑥 𝐵𝐵
72 𝑥 𝑆𝐶𝑟 𝑥 0,85
=
140−66 𝑡ℎ 𝑥 63 𝑘𝑔
72 𝑥 1,46
𝑚𝑔
𝑑𝐿
𝑥 0,85
= 28 ml/menit
■ Tgl 16/12 cr = 2,03 mg/dL
ClCr =
140−70 𝑡ℎ 𝑥 50 𝑘𝑔
72 𝑥 2,03
𝑚𝑔
𝑑𝐿
𝑥 0,85
= 20 ml/menit
Untuk wanita:
Kurus < 19 kg/m2
Normal 19-25 kg/m2
Overweight 25-30 kg/m2
Obesitas 30 - 40 kg/m2
Sumber: Pedoman Praktis
Terapi Gizi Medis DepKes RI
2003
Nama obat Rute Dosis 16/12 17/12 18/12 19/12
Aspilet po 80 mg/24 jam V V V V
Clopidogrel po 75 mg/24 jam V V V V
Atorvastatin Po 40 mg/24 jam V V V V
Syr laxadin Po 100 cc/24 jam V V V V
Alprazolam Po 0,5 mg/24 jam V V V V
Bisoprolol Po 2,5 mg/24 jam V V V V
Furosemid iv 40 mg/8 jam V STOP
UFH iv 500 UI /24 jam STOP
Warfarin po 2 mg/24 jam V V V V
Captopril Po 25 – 37,5 – 50 mg V STOP
Novorapid sc Ekstra 13 UI V STOP
Novorapid sc 3-3-0 V
Acarbose po 50 mg/8 jam V V V V
Captopril po 37,5 mg/8 jam V
Furosemid iv 20 mg/8jam V STOP
Furosemid po 40 mg/24 jam V V
Ramipril po 10 mg/24 jam V V
Novorapid S.C Ekstra 8 UI V STOP
Novorapid S.C 5-5-5 V
Keamanan Terapi pada Geriatri
Obat Beers criteria STOPP START Rekomendasi
Aprazolam Avoid
Pada penggunaan jangka panjang
> 1bulan dan golongan
benzodiazepin kerja panjang
Potensi ES seperti sedasi yang
panjang, bingung, ganggunan
keseimbangan, risiko jatuh
drug in the presence
of moderate-severe
depressive
symptoms lasting at
least three months
Penggunaan dosis kecil 0,25 -0,5
disarankan untuk pasien dengan
gangguan tidur karena durasi kerja
alprazolam lebih pendek
Namun jika indikasi sebgai anti anxiety
maka first linenya adalah gol SSRI
Monitoring : TTV,
Captoril, Furosemid -
Captopril dan furosemid dapat
menyebabkan AKI dengan
mekanisme acute intersisial
nefritis
Lanjutkan kombinasi
setelah baseline
serum kreatinin
tercapai
Pasien dengan CCT 10-50 mL/min
disarankan menggunakan 75% dosis
normal (Lacy, et.al.200) atau switch
kombinasi anti HT yang lain seperti
amlodipin 10 mg
Atau turunkan dosis furosemid
American beers criteria (2015). START/STOPP NHS (2015).
Keamanan Terapi pada Geriatri
Obat Beers criteria STOPP START Rekomendasi
Warfarin -
bleeding disorder
high risk of bleeding
hepatic impairment with impaired
clotting ability and raised INR
in the presence of
chronic atrial
fibrillation following
diagnosis of deep
vein thrombosis or
pulmonary
embolism if benefit
outweighs risk of
treatment
Walaupun tidak ada adjusment dose
pada pasien dengan gangguan ginjal
monitoring ketat harus dilakukan karena
efek bleeding akan meningkat karena
digunakan bersamaan dengan aspirin
Monitor : APTT, PTT, INR
START/STOPP NHS (2015).
Analisis dan Assessment
Nama obat Dosis Pasien Dosis Literatur Farmakodinamik/kinetik Assessment/Plan
Aspirin 80 mg/24 jam
Antiplatelet 80 – 320
mg
Avoid with patient <
10 ml/min clcr
Vd: 10 L; readily into most
body fluids and tissues
75% as salicyluric acid, 10%
as salicylic acid
Monitoring klinis pasien
PTT, APTT
Clopidogrel Po mg/24 jam
75 -162 mg dengan
dosis LD 300 mg
Parent drug: 98%;
metabolite: 94%
(50%); feces (46%)
Monitoringn Klinis pasien,
PTT, APTT
Atorvastatin
Po 40 mg/ 24 jam
10 -20 mg increase
40 mg
Vd 21L/kg
Ikatan proterin 93-98%
Metabolisme di hati (>90%)
dalam bentuk inaktif.
Ekskresi melalui urin (10%
utuh, 60% metabolit).
Lanjutkan penggunaan.
Monitoring TD.
CON’t
Nama obat Dosis Pasien Dosis Literatur Farmakodinamik/kinetik Assessment/Plan
Alprazolam 0,25 - 0,5 mg/24 jam
Dosing: Renal
Impairment No
guidelines for
adjustment; use
caution
Vd: 0.9-1.2 L/kg; enters breast
milk
Protein binding: 80%; primarily
to albumin
Bioavailability: 90%
T1/2 : Elderly: 16.3 hours
(range: 9-26.9 hours)
bisoprolol po 2,5 mg/ 24 jam
ClCr <40ml/mnt:
2,5mg/hari (DIH)
Ekskresi: urin (50% dalam
bentuk tak berubah), feses
(<2%)
Monitoring TTV
Warfarin 2 mg/24 jam
No adjustment
required, however,
patients with renal
failure have an
increased risk of
bleeding
complications.
Monitor closely
Anticoagulation: Oral: 24-72
hours
Peak effect: Full therapeutic
effect: 5-7 days; INR may
increase in 36-72 hours
Duration: 2-5 days
Distribution: 0.14 L/kg
Protein binding: 99%
Excretion: Urine (92%, primarily
as metabolites)
Monitoring ketat APTT, PTT
dengan target INR 2-3
setelah hari ke-3 s.d 5 hari
penggunaan
CON’t
Nama obat
Dosis
Pasien
Dosis Literatur Farmakodinamik/kinetik Assessment/Plan
Captoril
Hari
pertama
25-37,5-50
mg
Hari ke2
37,5 mg
Oral: Initial: 6.25 mg; followed by 12.5 mg 3
times/day; increase to 25 mg 3 times/day over
the next few days; following by gradual increase
to a goal of 50 mg 3 times/day (Some dosage
schedules increase the dosage more
aggressively to achieve goal dosage within the
first few days of initiation).
Renal impairment : Clcr 10-50 mL/minute:
Administer 75% of normal dose
Protein binding: 25% to 30%
Metabolism: 50%
Half-life elimination (renal and cardiac
function dependent):
Adults, healthy volunteers: 1.9 hours; Heart
failure: 2.06 hours; Anuria: 20-40 hours
Time to peak: 1 hour
Excretion: Urine (>95%) within 24 hours
(40% to 50% as unchanged drug)
Rekomendasi : Stop
captpril atau turunkan
menjadi 12,5 – 25/8
jam (maks) sampai
nilai baseline SCr
kembali normal
Monitoring : SCr bila
perlu, TTV
Ramipril
Po 10
mg/24 jam
Clcr <40 mL/minute: Administer 25% of normal
dose.
Renal failure and hypertension: Administer 1.25
mg once daily, titrated upward as possible.
Renal failure and heart failure: Administer 1.25
mg once daily, increasing to 1.25 mg twice daily
up to 2.5 mg twice daily as tolerated.
Binding 73%
Excretion: Urine (60%) and feces (40%) as
parent drug and metabolites
Rekomendasi :
menurunkan dosis
ramipril 1,25 mg/hari
Monitoring TTV,
kreatinin serum, K
Acarbose
50 mg/24
jam
Clcr <25 mL/minute: Peak plasma
concentrations were 5 times higher and AUCs
were 6 times larger than in volunteers with
normal renal function.
Significant renal dysfunction (Scr >2 mg/dL):
Use is not recommended.
Time to peak: Active drug: ~1 hour
Excretion: Urine (~34% as inactive
metabolites, <2% parent drug and active
metabolite); feces (~51% as unabsorbed
drug)
Disarankan Stop
acarbose
M.S. John Pathy, 2006. Principles and Practice of Geriatric Medicine Fourth Edition
Pharmaceutical Care Bidang Geriatri II
American Collage cardiology, 2017
Giuseppe Mancia, 2013. in : 2013
ESH/ESC Guidelines for the management
of arterial hypertension
American Collage cardiology, 2017
Giuseppe Mancia, 2013. in : 2013
ESH/ESC Guidelines for the
management of arterial hypertension
Pharmaceutical Care Bidang Geriatri II
Evi V. Nagle, et al, 2012. Antidepressants for depression in stage 3–5 chronic
kidney disease: a systematic review of pharmacokinetics, efficacy and safety
with recommendations by European Renal Best Practice (ERBP). Nephrol Dial
Transplant (2012) 27: 3736–3745
Daftar Pustaka
Lacy, C.F., Amstrong, L.L., Goldman, M.P. Lance, L.L., 2009. Drug
Information Handbook, 18 th edition. AphA, Lexi-comp inc.
Hundson, Ohio.
Pharmacit’s Letter, 2012, Potentially harmful drug in the ederly : beers
list.
Pharmacit’s Letter, 2011, STARTing and STOPPing Medications in the
Elderly.
TERIMA KASIH

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Pharmaceutical Care Bidang Geriatri II

  • 1. PHARMACEUTICAL CARE BIDANG GERIATRI STEMI INFERIOR 3 VD, DM2, PAF, AKI . Senin, 23 Okt
  • 2. Identitas Pasien ■ Nama : Ny R ■ No CM : 01 02 25 ** ■ Alamat : Yogya ■ Tanggal lahir : 1 Feb 19467 (70 tahun) ■ BB/TB : 50 kg/ 145 cm ■ Diagnosa : 1. Stemi Inferior 2. DM2 3. AKI 4. PAF ■ Bangsal : Anggrek 1 km 1 ■ Status pasien : JKN non PBI ■ MRS : 13/12/2017 ■ KRS : 19/12/2017
  • 3. Data Subjektif Keluhan Utama MRS: Nyeri Dada RPS: ± 1 hari SMRS mengeluh nyeri pada dada sebelah kiria setelah menyapu pada sore hari, makin memberat pada malam hari. Pasien sempat mengatakan minta dikerok namun tidak sembuh nyeri makin hebat dan sesak. Pasien sempat dibawa ke rs panti nugroho merasakan sesak nafas dan gelisah  dikatakan EPA dan sempat dilakukan intubasi RPD: - ROD: Pasien sempat diberikan obat saat di rs panti nugroho yaitu aspilet 320 mg, clopidogrel 300 mg, ISDN 5 mg SL, Furosemid 2 ampul, morfin 2 mg, omeprazole 1 A, Novorapid 4 UI Aspek Geriatri: ADL premorbid  dibantu sebagian Kognitif  baik Mental  baik, tidak ada stress Support system  tinggal serumah dengan anak Alergi Obat: -
  • 4. Data Objektif Parameter Tanggal 13/12 ICCU 14/12 15/12 16/12 17/12 18/12 19/12 TD (mmHg) 150/80 140/80 138/80 146/78 124/63 114/60 105/75 Nadi (x/mnt) 82 80 80 72 68 68 70 RR (x/mnt) 20 20 22 22 20 18 18 Suhu (oC) 36,7 36,8 36,8 36,1 36,2 36 SpO2 (%) 95,5 97,5 97,5 93 99 Tanda-tanda Vital
  • 5. Parameter Tanggal 13/12 IGD 14/12 15/12 16/12 17/12 18/12 19/12 KU Sdg CM Sdg CM Sdg CM Sdg CM Sdg CM Sdg CM Sdg CM Lemas + + + + + + + Sesak Nafas terasa berat + + - - - - Perkembangan Klinis
  • 6. Data Laboratorium Parameter Nilai Rujukan 13/12 14/12 15/12 16/12 17/12 18/12 AL 4,5 – 11,5 Rb/MMk 14,3 Hb 13 - 18 g% 9,6 Hmt 40 - 54 % 29,0 BUN 6-20 mg/dL 17,8 38 Creatinin 0,7 - 1,2 mg/dL 1,46 2,03 CCT mL/min 28 GDS 80-140 mg/dL 236 GDP 80 - 110 mg/dL 187 178 189 HbA1c < % 7 8,5% LDL direct mg/dL 130 SGOT 5-35 u/L 43 SGPT 5-35 u/L 22 PTT 10 - 15 detik 19,2 aPTT 21 - 45 detik 36,1 69,4 72,7 55,7 92 INR 0,80-1,20 detik 1,18 1,49 Na 135-144 mmol/L 142 K 3,5-5,1 mEq 3,37 4,86 Cl 97-106 mmol/L 111
  • 7. Perhitungan ClCr Umur: 70 tahun BB/TB = 50 kg/145 cm 𝐵𝑀𝐼 = 50 𝑘𝑔 (1,45)2 = 23,78 kg/m2 ■ Tgl 13/12 cr = 1,46 mg/dL ClCr = 140−𝑢𝑚𝑢𝑟 𝑥 𝐵𝐵 72 𝑥 𝑆𝐶𝑟 𝑥 0,85 = 140−66 𝑡ℎ 𝑥 63 𝑘𝑔 72 𝑥 1,46 𝑚𝑔 𝑑𝐿 𝑥 0,85 = 28 ml/menit ■ Tgl 16/12 cr = 2,03 mg/dL ClCr = 140−70 𝑡ℎ 𝑥 50 𝑘𝑔 72 𝑥 2,03 𝑚𝑔 𝑑𝐿 𝑥 0,85 = 20 ml/menit Untuk wanita: Kurus < 19 kg/m2 Normal 19-25 kg/m2 Overweight 25-30 kg/m2 Obesitas 30 - 40 kg/m2 Sumber: Pedoman Praktis Terapi Gizi Medis DepKes RI 2003
  • 8. Nama obat Rute Dosis 16/12 17/12 18/12 19/12 Aspilet po 80 mg/24 jam V V V V Clopidogrel po 75 mg/24 jam V V V V Atorvastatin Po 40 mg/24 jam V V V V Syr laxadin Po 100 cc/24 jam V V V V Alprazolam Po 0,5 mg/24 jam V V V V Bisoprolol Po 2,5 mg/24 jam V V V V Furosemid iv 40 mg/8 jam V STOP UFH iv 500 UI /24 jam STOP Warfarin po 2 mg/24 jam V V V V Captopril Po 25 – 37,5 – 50 mg V STOP Novorapid sc Ekstra 13 UI V STOP Novorapid sc 3-3-0 V Acarbose po 50 mg/8 jam V V V V Captopril po 37,5 mg/8 jam V Furosemid iv 20 mg/8jam V STOP Furosemid po 40 mg/24 jam V V Ramipril po 10 mg/24 jam V V Novorapid S.C Ekstra 8 UI V STOP Novorapid S.C 5-5-5 V
  • 9. Keamanan Terapi pada Geriatri Obat Beers criteria STOPP START Rekomendasi Aprazolam Avoid Pada penggunaan jangka panjang > 1bulan dan golongan benzodiazepin kerja panjang Potensi ES seperti sedasi yang panjang, bingung, ganggunan keseimbangan, risiko jatuh drug in the presence of moderate-severe depressive symptoms lasting at least three months Penggunaan dosis kecil 0,25 -0,5 disarankan untuk pasien dengan gangguan tidur karena durasi kerja alprazolam lebih pendek Namun jika indikasi sebgai anti anxiety maka first linenya adalah gol SSRI Monitoring : TTV, Captoril, Furosemid - Captopril dan furosemid dapat menyebabkan AKI dengan mekanisme acute intersisial nefritis Lanjutkan kombinasi setelah baseline serum kreatinin tercapai Pasien dengan CCT 10-50 mL/min disarankan menggunakan 75% dosis normal (Lacy, et.al.200) atau switch kombinasi anti HT yang lain seperti amlodipin 10 mg Atau turunkan dosis furosemid American beers criteria (2015). START/STOPP NHS (2015).
  • 10. Keamanan Terapi pada Geriatri Obat Beers criteria STOPP START Rekomendasi Warfarin - bleeding disorder high risk of bleeding hepatic impairment with impaired clotting ability and raised INR in the presence of chronic atrial fibrillation following diagnosis of deep vein thrombosis or pulmonary embolism if benefit outweighs risk of treatment Walaupun tidak ada adjusment dose pada pasien dengan gangguan ginjal monitoring ketat harus dilakukan karena efek bleeding akan meningkat karena digunakan bersamaan dengan aspirin Monitor : APTT, PTT, INR START/STOPP NHS (2015).
  • 11. Analisis dan Assessment Nama obat Dosis Pasien Dosis Literatur Farmakodinamik/kinetik Assessment/Plan Aspirin 80 mg/24 jam Antiplatelet 80 – 320 mg Avoid with patient < 10 ml/min clcr Vd: 10 L; readily into most body fluids and tissues 75% as salicyluric acid, 10% as salicylic acid Monitoring klinis pasien PTT, APTT Clopidogrel Po mg/24 jam 75 -162 mg dengan dosis LD 300 mg Parent drug: 98%; metabolite: 94% (50%); feces (46%) Monitoringn Klinis pasien, PTT, APTT Atorvastatin Po 40 mg/ 24 jam 10 -20 mg increase 40 mg Vd 21L/kg Ikatan proterin 93-98% Metabolisme di hati (>90%) dalam bentuk inaktif. Ekskresi melalui urin (10% utuh, 60% metabolit). Lanjutkan penggunaan. Monitoring TD.
  • 12. CON’t Nama obat Dosis Pasien Dosis Literatur Farmakodinamik/kinetik Assessment/Plan Alprazolam 0,25 - 0,5 mg/24 jam Dosing: Renal Impairment No guidelines for adjustment; use caution Vd: 0.9-1.2 L/kg; enters breast milk Protein binding: 80%; primarily to albumin Bioavailability: 90% T1/2 : Elderly: 16.3 hours (range: 9-26.9 hours) bisoprolol po 2,5 mg/ 24 jam ClCr <40ml/mnt: 2,5mg/hari (DIH) Ekskresi: urin (50% dalam bentuk tak berubah), feses (<2%) Monitoring TTV Warfarin 2 mg/24 jam No adjustment required, however, patients with renal failure have an increased risk of bleeding complications. Monitor closely Anticoagulation: Oral: 24-72 hours Peak effect: Full therapeutic effect: 5-7 days; INR may increase in 36-72 hours Duration: 2-5 days Distribution: 0.14 L/kg Protein binding: 99% Excretion: Urine (92%, primarily as metabolites) Monitoring ketat APTT, PTT dengan target INR 2-3 setelah hari ke-3 s.d 5 hari penggunaan
  • 13. CON’t Nama obat Dosis Pasien Dosis Literatur Farmakodinamik/kinetik Assessment/Plan Captoril Hari pertama 25-37,5-50 mg Hari ke2 37,5 mg Oral: Initial: 6.25 mg; followed by 12.5 mg 3 times/day; increase to 25 mg 3 times/day over the next few days; following by gradual increase to a goal of 50 mg 3 times/day (Some dosage schedules increase the dosage more aggressively to achieve goal dosage within the first few days of initiation). Renal impairment : Clcr 10-50 mL/minute: Administer 75% of normal dose Protein binding: 25% to 30% Metabolism: 50% Half-life elimination (renal and cardiac function dependent): Adults, healthy volunteers: 1.9 hours; Heart failure: 2.06 hours; Anuria: 20-40 hours Time to peak: 1 hour Excretion: Urine (>95%) within 24 hours (40% to 50% as unchanged drug) Rekomendasi : Stop captpril atau turunkan menjadi 12,5 – 25/8 jam (maks) sampai nilai baseline SCr kembali normal Monitoring : SCr bila perlu, TTV Ramipril Po 10 mg/24 jam Clcr <40 mL/minute: Administer 25% of normal dose. Renal failure and hypertension: Administer 1.25 mg once daily, titrated upward as possible. Renal failure and heart failure: Administer 1.25 mg once daily, increasing to 1.25 mg twice daily up to 2.5 mg twice daily as tolerated. Binding 73% Excretion: Urine (60%) and feces (40%) as parent drug and metabolites Rekomendasi : menurunkan dosis ramipril 1,25 mg/hari Monitoring TTV, kreatinin serum, K Acarbose 50 mg/24 jam Clcr <25 mL/minute: Peak plasma concentrations were 5 times higher and AUCs were 6 times larger than in volunteers with normal renal function. Significant renal dysfunction (Scr >2 mg/dL): Use is not recommended. Time to peak: Active drug: ~1 hour Excretion: Urine (~34% as inactive metabolites, <2% parent drug and active metabolite); feces (~51% as unabsorbed drug) Disarankan Stop acarbose
  • 14. M.S. John Pathy, 2006. Principles and Practice of Geriatric Medicine Fourth Edition
  • 16. American Collage cardiology, 2017 Giuseppe Mancia, 2013. in : 2013 ESH/ESC Guidelines for the management of arterial hypertension
  • 17. American Collage cardiology, 2017 Giuseppe Mancia, 2013. in : 2013 ESH/ESC Guidelines for the management of arterial hypertension
  • 19. Evi V. Nagle, et al, 2012. Antidepressants for depression in stage 3–5 chronic kidney disease: a systematic review of pharmacokinetics, efficacy and safety with recommendations by European Renal Best Practice (ERBP). Nephrol Dial Transplant (2012) 27: 3736–3745
  • 20. Daftar Pustaka Lacy, C.F., Amstrong, L.L., Goldman, M.P. Lance, L.L., 2009. Drug Information Handbook, 18 th edition. AphA, Lexi-comp inc. Hundson, Ohio. Pharmacit’s Letter, 2012, Potentially harmful drug in the ederly : beers list. Pharmacit’s Letter, 2011, STARTing and STOPPing Medications in the Elderly.

Hinweis der Redaktion

  1. STEMI  ST ELEVASI MIOKARD INFARCTION DT  DM 2  DIABETES MELITUS TIPE 2 PAF  PAROXYSMAL ATRIAL FIBRILATION AKI  ACUTE KIDNEY INJURY
  2. Pasien 3 hari di iccu setelah PCI  pindah ke bangsal anggrek pada tanggal 16 Des 2017 Stemi Inferior  ST ELEVASI MIOKARD INFARCTION pada bagian inferior (belakang) DM 2  Diabetes Melitus tipe 2 AKI  Akut Kidney Injury PAF  Paroxysmal Atrial Fibrilasi
  3. aPTT: actived partial thromboplastin time, PPT: prothrombin time  proses pembekuan darah CCT: Clearence Clirens Total (15-29 penurunan fungsi berat) AL : angka leukosit
  4. Peningkatan GFR pada tanggal 16/12  perlu perhatian Drug induced AKI
  5. Noviorapid ekstra  perhitungan dosis berdasarkan nilai glukosa, setiap peningkatan glukosa 10 – 20 mg/dL akan diberikan kenaikan dosis Novorapid 4 U Pemberian captopril 25 – 37,5 – 50 adalah berdasarkan slow to slow dengan alasan menyesuaikan respon dari RAAS, selain itu juga Digunakan untuk mengkompensasi penggunaan captopril sebelum mrs untuk mengurangi sub terapetik sehingga dosis yang digunakan Awal adalah 25 mg dengan maksimal dosis adalah 50 mg/8 jam
  6. Secara farmakokinetik obat dengan afinitas protein tinggi dan lipofil memiliki kecendrungan memiliki VD memanjang karena Total body composition tersubstitusi oleh lemak 50%, sehingga efek obat dengan sifat hidrofil akan berada dalam plasma darah Dalam konsentrasi tinggi (noted)
  7. Secara farmakokinetik obat dengan afinitas protein tinggi dan lipofil memiliki kecendrungan memiliki VD memanjang karena Total body composition tersubstitusi oleh lemak 50%, sehingga onset obat lambat dicapai Penggunaan rampril melebihi dosis dimana pada pasien dengan CCT < 40 mL disarankan menggunakan dosis 25 % dosis normal Atau 1,25 mg/hari
  8. Candesartan dapat menyebabkan hiperkalemi dan memburuknya fungsi renal. Cande + amlo  ikatan proteinnya tinggi, sedangkan px lansia dan mengalami penurunan albumin beresiko mengalami efek toksik yaitu menyebabkan hipotensi.
  9. anti HT bb blocker dan CCB dapat diberikan pada pasien dengan post infark (LOE IA) dan dapat dikombinasikan dengan diuretik Jika terjadi penurunan fungsi ventrikel
  10. Meta analisis kombinasi dual anti hipertensi, dimana kombinasi kedua anti HT yang di gunakan yaitu ramipril dan furosemid Merupakan DIRI (Drug Induced Renal Injury) dengan mekanisme sama menyebabkan deplesi cairan dalam kapiler arteriol afferent Atau penurunan laju filtrasi glomerolus (gangguan ginjal prerenal)
  11. Paroxysmal atrial fibrilasi adalah  atrial fibrilasi yang terjadi secara spontan atau karena intervensi (PCI atau defebrilator) dengan onset 7 hari dan gejalanya bisa terjadi lagi (rekurensi) dengan frekuensi yang bervariasi